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Menthol-Camphor-Thymol-Eucalyptus Compound as a Novel Adjuvant Therapy in Fluconazole-Treated Candida parapsilosis Onychomycosis: A Case Report Nurrachmat Mulianto; Nurul Hidayati
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 9 No. 8 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v9i8.1348

Background: Onychomycosis, a fungal infection of the nail apparatus, presents a therapeutic challenge due to its recalcitrant nature and the limitations of current antifungal regimens, including potential side effects and prolonged treatment durations. Candida parapsilosis is an increasingly recognized, yet less commonly reported, yeast pathogen in onychomycosis, particularly in immunocompromised individuals or those with specific comorbidities. The exploration of effective, safe, and accessible adjuvant therapies is crucial to enhance treatment outcomes. This report details the use of an over-the-counter menthol-camphor-thymol-eucalyptus compound as an adjuvant to oral fluconazole. Case presentation: A 69-year-old male, a gold washer by occupation with a two-month history of rheumatoid arthritis (RA) treated with methotrexate, hydroxychloroquine, methylprednisolone, and celecoxib, presented with a four-month history of yellowish-brown discoloration, uneven texture, and brittleness of both thumb nails. Dermatological examination revealed onychodystrophy, subungual hyperkeratosis, and yellowish-brown discoloration of the bilateral thumb nail plates. Dermoscopy confirmed these findings. Fungal culture of nail clippings identified Candida parapsilosis. The patient was treated with oral fluconazole 150 mg weekly for three months and twice-daily topical application of menthol-camphor-thymol-eucalyptus compound under plastic occlusion. Significant clinical improvement in nail color and texture, with no onycholysis, was observed at the 6-week follow-up. At the 3-month evaluation, fungal culture was negative, and liver function tests remained within normal limits. Conclusion: This case demonstrates the successful use of a menthol-camphor-thymol-eucalyptus compound as an adjuvant to oral fluconazole in treating Candida parapsilosis onychomycosis in an elderly patient with RA. The combination therapy was well-tolerated and led to clinical and mycological resolution, suggesting a promising, accessible, and cost-effective adjunctive therapeutic strategy.

Menthol-Camphor-Thymol-Eucalyptus Compound as a Novel Adjuvant Therapy in Fluconazole-Treated Candida parapsilosis Onychomycosis: A Case Report Nurrachmat Mulianto; Nurul Hidayati
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 9 No. 8 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v9i8.1348

Background: Onychomycosis, a fungal infection of the nail apparatus, presents a therapeutic challenge due to its recalcitrant nature and the limitations of current antifungal regimens, including potential side effects and prolonged treatment durations. Candida parapsilosis is an increasingly recognized, yet less commonly reported, yeast pathogen in onychomycosis, particularly in immunocompromised individuals or those with specific comorbidities. The exploration of effective, safe, and accessible adjuvant therapies is crucial to enhance treatment outcomes. This report details the use of an over-the-counter menthol-camphor-thymol-eucalyptus compound as an adjuvant to oral fluconazole. Case presentation: A 69-year-old male, a gold washer by occupation with a two-month history of rheumatoid arthritis (RA) treated with methotrexate, hydroxychloroquine, methylprednisolone, and celecoxib, presented with a four-month history of yellowish-brown discoloration, uneven texture, and brittleness of both thumb nails. Dermatological examination revealed onychodystrophy, subungual hyperkeratosis, and yellowish-brown discoloration of the bilateral thumb nail plates. Dermoscopy confirmed these findings. Fungal culture of nail clippings identified Candida parapsilosis. The patient was treated with oral fluconazole 150 mg weekly for three months and twice-daily topical application of menthol-camphor-thymol-eucalyptus compound under plastic occlusion. Significant clinical improvement in nail color and texture, with no onycholysis, was observed at the 6-week follow-up. At the 3-month evaluation, fungal culture was negative, and liver function tests remained within normal limits. Conclusion: This case demonstrates the successful use of a menthol-camphor-thymol-eucalyptus compound as an adjuvant to oral fluconazole in treating Candida parapsilosis onychomycosis in an elderly patient with RA. The combination therapy was well-tolerated and led to clinical and mycological resolution, suggesting a promising, accessible, and cost-effective adjunctive therapeutic strategy.

Drug-Induced Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Retrospective Study on Causative Agents and Patient Profiles in an Indonesian Hospital Setting Nurrachmat Mulianto; Lidjaja, Lifesia Natali
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 9 No. 7 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v9i7.1327

Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) represent rare, severe mucocutaneous adverse drug reactions characterized by extensive epidermal necrosis and significant morbidity and mortality. Understanding the specific causative agents and patient profiles within local populations is crucial for early diagnosis and management. This study aimed to characterize SJS/TEN cases in a tertiary hospital setting in Indonesia. Methods: A retrospective descriptive study was conducted using secondary data from medical records of patients diagnosed with SJS, SJS/TEN overlap, and TEN admitted to the inpatient installation of Dr. Moewardi General Hospital, Surakarta, Indonesia, between January 2022 and December 2024. Data collected included demographics (age, gender), comorbidities, diagnosis classification (SJS, SJS/TEN overlap, TEN), suspected causative drugs, length of hospital stay, SCORTEN score, and patient outcome (discharged alive or deceased). Total sampling was employed, excluding records with incomplete data. Data were compiled and analyzed descriptively. Results: Fifty-one patients were included, with a slight female predominance (52.94%). The largest age group affected was 19-59 years (60.78%). The distribution of diagnoses was SJS (41.18%), SJS/TEN overlap (31.37%), and TEN (27.45%). The mean SCORTEN score for the cohort was 2. The most common suspected causative drug classes were antibiotics (25.71%), followed by analgesic-antipyretics (24.29%), and anticonvulsants (22.86%). Carbamazepine (11.43%) and amoxicillin (10%) were frequent individual culprits. Epilepsy (13.73%) and diabetes mellitus (11.76%) were common comorbidities, although a significant portion (33.33%) had no recorded comorbidity. The mean length of stay was 9 days. Overall mortality was 15.68%, with higher rates observed in TEN (28.57%) compared to SJS (9.52%) and SJS/TEN overlap (12.5%). Conclusion: SJS/TEN affected predominantly adults, with antibiotics, analgesics, and anticonvulsants being the most implicated drug classes. While mortality was considerable, it appeared lower than some international reports, particularly for TEN. Recognizing common causative agents and patient risk factors, such as specific comorbidities like epilepsy and diabetes, can aid clinicians in early identification and prompt management of these life-threatening conditions.

UVB-Induced Oxidative Collapse and Melanogenic Activation in a Rat Model of Cutaneous Hyperpigmentation: A Multi-Parametric Analysis Sesia Pradestine; Endra Yustin Ellistasari; Nurrachmat Mulianto; Indah Julianto; Muhammad Eko Irawanto; Nugrohoaji Dharmawan
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 9 No. 11 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v9i11.1442

Background: Ultraviolet B (UVB) radiation is a primary driver of cutaneous hyperpigmentation disorders, with oxidative stress recognized as a key pathogenic mechanism. However, a comprehensive, multi-level characterization of the causal link between chronic UVB exposure and the resulting oxidative, histological, and melanogenic responses is needed. This study aimed to quantitatively validate a preclinical model of UVB-induced hyperpigmentation by characterizing the reciprocal regulation of key oxidative stress biomarkers and correlating these changes with objective histological evidence of hyperpigmentation. Methods: This controlled in vivo experimental study used 14 male Sprague Dawley rats, divided into a control group (KN; n=7) and a UVB-exposed group (KP; n=7). The KP group received chronic UVB radiation (300 mJ/cm² daily, 5 days/week for 4 weeks). Dorsal skin tissue was harvested for analysis. Oxidative stress was assessed by quantifying malondialdehyde (MDA), superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx) levels via ELISA. Hyperpigmentation was objectively validated and quantified using Fontana-Masson staining for melanin deposition and immunohistochemistry for microphthalmia-associated transcription factor (MITF). Results: Chronic UVB exposure induced significant hyperpigmentation, confirmed by a 5.8-fold increase in epidermal melanin content (p < 0.001) and a 4.1-fold increase in the number of MITF-positive melanocytes (p < 0.001) in the KP group. This was accompanied by a profound oxidative imbalance: MDA levels increased by 7.5-fold (p < 0.001), while the activities of SOD, CAT, and GPx decreased by 80.5%, 65.2%, and 71.4%, respectively (all p < 0.001). A strong negative correlation was observed between MDA and all antioxidant enzymes, particularly SOD (r = -0.985, p < 0.001). Conclusion: Chronic UVB exposure directly triggers a collapse of the cutaneous antioxidant network, leading to severe lipid peroxidation. This state of profound oxidative stress is causally linked to melanocyte activation and excessive melanin synthesis, driving the hyperpigmentation phenotype. This robustly validated preclinical model provides a powerful platform for investigating the molecular pathophysiology of UVB-induced pigmentary disorders and for evaluating novel therapeutic interventions.

A Retrospective Analysis of Clinical Characteristics and Neutrophil-to-Lymphocyte Ratio in Hospitalized Indonesian Patients with Pemphigus Vulgaris and Bullous Pemphigoid: A Single-Center Experience Azhar Arrosyid; Nurrachmat Mulianto
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 9 No. 11 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v9i11.1445

Background: Comprehensive clinical-epidemiological data on severe autoimmune bullous diseases (ABDs) from Southeast Asian populations are notably scarce. Pemphigus vulgaris (PV) and bullous pemphigoid (BP) are the most common ABDs, and understanding their presentation in diverse ethnic and geographic contexts is crucial for global health equity. This study’s primary aim was to characterize a cohort of hospitalized ABD patients in Central Java, Indonesia, and to secondarily explore the behavior of the neutrophil-to-lymphocyte ratio (NLR) as an inflammatory marker within this real-world clinical setting. Methods: A retrospective, cross-sectional study was conducted at a tertiary referral hospital in Surakarta, Indonesia. The study included all patients admitted with a final diagnosis of PV or BP between January 2019 and December 2023. Comprehensive data on demographics, documented comorbidities, duration of hospitalization, and admission hematological parameters were extracted from medical records. Clinical characteristics were compared, and the non-parametric Mann-Whitney U test was used to analyze the difference in NLR. A post-hoc power analysis was performed to contextualize the hematological findings. Results: This study provides a detailed clinical profile of 30 hospitalized ABD patients. The PV cohort (n=17) was characterized by a younger age of onset (mean age 54.29 ± 14.83 years) and a strong female predominance (70.6%). In contrast, the BP cohort (n=13) was older (mean age 63.08 ± 22.01 years) with a balanced gender distribution. A key finding was that patients with PV had a significantly longer duration of hospitalization than those with BP (13.24 vs. 10.15 days, p < 0.05). The mean NLR was descriptively higher in BP (10.56 ± 7.22) than in PV (9.43 ± 6.14), but this difference was not statistically significant (p = 0.770), a finding consistent with the study’s critically low statistical power of 9.8%. Conclusion: This study presents a valuable clinical and epidemiological snapshot of hospitalized patients with PV and BP in an underrepresented Indonesian population, highlighting a significantly greater clinical burden for PV as quantified by length of stay. The exploratory analysis of the NLR was inconclusive and should not be interpreted as definitive evidence against its utility. Instead, it serves as a powerful illustration of how the effects of low statistical power and overwhelming, unmeasured confounding from disease severity and corticosteroid treatment present profound challenges to the validation of non-specific biomarkers in complex, real-world clinical scenarios.

UVB-Induced Oxidative Collapse and Melanogenic Activation in a Rat Model of Cutaneous Hyperpigmentation: A Multi-Parametric Analysis Sesia Pradestine; Endra Yustin Ellistasari; Nurrachmat Mulianto; Indah Julianto; Muhammad Eko Irawanto; Nugrohoaji Dharmawan
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 9 No. 11 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v9i11.1442

Background: Ultraviolet B (UVB) radiation is a primary driver of cutaneous hyperpigmentation disorders, with oxidative stress recognized as a key pathogenic mechanism. However, a comprehensive, multi-level characterization of the causal link between chronic UVB exposure and the resulting oxidative, histological, and melanogenic responses is needed. This study aimed to quantitatively validate a preclinical model of UVB-induced hyperpigmentation by characterizing the reciprocal regulation of key oxidative stress biomarkers and correlating these changes with objective histological evidence of hyperpigmentation. Methods: This controlled in vivo experimental study used 14 male Sprague Dawley rats, divided into a control group (KN; n=7) and a UVB-exposed group (KP; n=7). The KP group received chronic UVB radiation (300 mJ/cm² daily, 5 days/week for 4 weeks). Dorsal skin tissue was harvested for analysis. Oxidative stress was assessed by quantifying malondialdehyde (MDA), superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx) levels via ELISA. Hyperpigmentation was objectively validated and quantified using Fontana-Masson staining for melanin deposition and immunohistochemistry for microphthalmia-associated transcription factor (MITF). Results: Chronic UVB exposure induced significant hyperpigmentation, confirmed by a 5.8-fold increase in epidermal melanin content (p < 0.001) and a 4.1-fold increase in the number of MITF-positive melanocytes (p < 0.001) in the KP group. This was accompanied by a profound oxidative imbalance: MDA levels increased by 7.5-fold (p < 0.001), while the activities of SOD, CAT, and GPx decreased by 80.5%, 65.2%, and 71.4%, respectively (all p < 0.001). A strong negative correlation was observed between MDA and all antioxidant enzymes, particularly SOD (r = -0.985, p < 0.001). Conclusion: Chronic UVB exposure directly triggers a collapse of the cutaneous antioxidant network, leading to severe lipid peroxidation. This state of profound oxidative stress is causally linked to melanocyte activation and excessive melanin synthesis, driving the hyperpigmentation phenotype. This robustly validated preclinical model provides a powerful platform for investigating the molecular pathophysiology of UVB-induced pigmentary disorders and for evaluating novel therapeutic interventions.

A Retrospective Analysis of Clinical Characteristics and Neutrophil-to-Lymphocyte Ratio in Hospitalized Indonesian Patients with Pemphigus Vulgaris and Bullous Pemphigoid: A Single-Center Experience Azhar Arrosyid; Nurrachmat Mulianto
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 9 No. 11 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v9i11.1445

Background: Comprehensive clinical-epidemiological data on severe autoimmune bullous diseases (ABDs) from Southeast Asian populations are notably scarce. Pemphigus vulgaris (PV) and bullous pemphigoid (BP) are the most common ABDs, and understanding their presentation in diverse ethnic and geographic contexts is crucial for global health equity. This study’s primary aim was to characterize a cohort of hospitalized ABD patients in Central Java, Indonesia, and to secondarily explore the behavior of the neutrophil-to-lymphocyte ratio (NLR) as an inflammatory marker within this real-world clinical setting. Methods: A retrospective, cross-sectional study was conducted at a tertiary referral hospital in Surakarta, Indonesia. The study included all patients admitted with a final diagnosis of PV or BP between January 2019 and December 2023. Comprehensive data on demographics, documented comorbidities, duration of hospitalization, and admission hematological parameters were extracted from medical records. Clinical characteristics were compared, and the non-parametric Mann-Whitney U test was used to analyze the difference in NLR. A post-hoc power analysis was performed to contextualize the hematological findings. Results: This study provides a detailed clinical profile of 30 hospitalized ABD patients. The PV cohort (n=17) was characterized by a younger age of onset (mean age 54.29 ± 14.83 years) and a strong female predominance (70.6%). In contrast, the BP cohort (n=13) was older (mean age 63.08 ± 22.01 years) with a balanced gender distribution. A key finding was that patients with PV had a significantly longer duration of hospitalization than those with BP (13.24 vs. 10.15 days, p < 0.05). The mean NLR was descriptively higher in BP (10.56 ± 7.22) than in PV (9.43 ± 6.14), but this difference was not statistically significant (p = 0.770), a finding consistent with the study’s critically low statistical power of 9.8%. Conclusion: This study presents a valuable clinical and epidemiological snapshot of hospitalized patients with PV and BP in an underrepresented Indonesian population, highlighting a significantly greater clinical burden for PV as quantified by length of stay. The exploratory analysis of the NLR was inconclusive and should not be interpreted as definitive evidence against its utility. Instead, it serves as a powerful illustration of how the effects of low statistical power and overwhelming, unmeasured confounding from disease severity and corticosteroid treatment present profound challenges to the validation of non-specific biomarkers in complex, real-world clinical scenarios.

Dermoscopy Of Onychomycosis: A Literature Review Primisawitri, Pratiwi Prasetya; Mulianto, Nurrachmat
Indonesian Basic and Experimental Health Sciences Vol. 13 No. 1 (2024): November
Publisher : Rumah Sakit Umum Daerah Dr. Moewardi

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.11594/ibehs.vol13iss1pp23-33

Background: Onychomycosis is a fungal infection of the nails. Onychomycosis is caused by dermatophytes, non-dermatophyte molds, and non-dermatophyte fungi. Dermoscopy examination has gradually been used as a modern diagnostic method to assess non-invasive nail abnormalities that are easy and inexpensive to visualize abnormal microscopic features of the nail. However, it is still uncommon for medical personnel to diagnose onychomycosis using dermoscopy. Purpose: To provide information on the benefits of the nail dermoscopy technique that can diagnose onychomycosis and describe observable dermoscopic findings. Results: Dermoscopy findings on onychomycosis showed a diverse picture depending on the type. Distal and lateral subungual onychomycosis shows the proximal margin of the onycholytic area with spikes leading to proximal folds and longitudinal striae. White superficial onychomycosis shows large, brittle, irregularly spreading white-yellow patches on the nail's surface. Proximal subungual onychomycosis has one or more transverse white bands on the inner nail plate, while total dystrophic onychomycosis shows longitudinal striae and spikes and irregular distal terminations. Conclusion: Nail dermoscopy improves quality and simplifies examination to establish the diagnosis of onychomycosis because it can guide clinicians in conducting screening, choosing the best time for mycological sampling, and making therapeutic decisions.

The Differential Biopsychosocial Burden of Psoriasis and Vitiligo: A Comparative Analysis of Participation Restriction and its Clinical and Psychiatric Correlates Nurrachmat Mulianto; Shelly Lavenia Sambodo; Muhammad Eko Irawanto; Arie Kusumawardani
Open Access Indonesian Journal of Medical Reviews Vol. 5 No. 6 (2025): Open Access Indonesian Journal of Medical Reviews
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/oaijmr.v5i6.805

Visible skin diseases like psoriasis vulgaris and vitiligo impose a significant psychosocial burden. However, the comparative impact on real-world functioning and the interplay of clinical, social, and psychiatric factors remain poorly understood, particularly in non-Western populations. This study aimed to quantitatively compare participation restriction between these two conditions and to identify its key biopsychosocial predictors. This comparative cross-sectional study, conducted in a tertiary Indonesian hospital, enrolled 50 patients (25 with psoriasis vulgaris, 25 with non-segmental vitiligo). The primary outcome was participation restriction, measured by the 18-item Participation Scale (P-Scale). Clinical severity was assessed using the Psoriasis Area and Severity Index (PASI) and Vitiligo Area Scoring Index (VASI). Crucially, depressive and anxiety symptoms were screened using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scale, respectively. A hierarchical multiple linear regression analysis was performed to identify predictors of participation restriction. Patients with psoriasis reported profoundly higher mean P-Scale scores (43.16 ± 5.01) compared to those with vitiligo (25.72 ± 4.21; p < 0.001), indicating more severe restrictions. Psoriasis patients also exhibited significantly higher scores for depressive symptoms (PHQ-9: 11.52 ± 3.18 vs. 5.68 ± 2.29; p < 0.001) and anxiety symptoms (GAD-7: 10.24 ± 2.95 vs. 5.12 ± 2.15; p < 0.001). The hierarchical regression model was highly significant (F(7, 42) = 28.14, p < 0.001), explaining 82.4% of the variance in P-Scale scores. After controlling for demographic and clinical factors, a diagnosis of psoriasis (β = 0.45, p < 0.001), higher clinical severity (β = 0.28, p = 0.002), and higher depressive symptom severity (PHQ-9 score; β = 0.39, p < 0.001) were significant independent predictors of greater participation restriction. In conclusion, psoriasis vulgaris is associated with a dramatically greater burden of participation restriction than vitiligo. This burden is driven by a complex interplay of the disease's clinical severity, its inherent diagnosis-specific factors, and, critically, comorbid depressive symptoms. These findings underscore the necessity of a biopsychosocial approach in dermatology, advocating for routine mental health screening and integrated care models to address the multifaceted drivers of disability in patients with chronic inflammatory skin disease.

Erythema Nodosum Leprosum as a Harbinger of Relapse in Multibacillary Leprosy: A Clinico-Histopathological Case Study Benedikta Lauda; Nurrachmat Mulianto
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 9 No. 12 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v9i12.1468

Background: Leprosy, a chronic granulomatous disease caused by Mycobacterium leprae, presents formidable long-term management challenges. In the post-elimination era, differentiating a true bacteriological relapse from a late-onset Erythema Nodosum Leprosum (ENL) reaction in patients who have completed multidrug therapy (MDT) is a critical diagnostic dilemma. Misdiagnosis can lead to inappropriate treatment, risking disease progression and irreversible nerve damage. Case presentation: A 30-year-old male presented with a severe, systemic inflammatory illness two years after completing MDT for lepromatous leprosy. His symptoms included crops of painful, erythematous nodules, fever, and arthralgia. While clinically suggestive of a severe ENL reaction, a slit-skin smear revealed a paradoxically high bacterial index (BI) of +5 with a morphological index (MI) of 0%. A skin biopsy was performed for definitive diagnosis. Histopathology revealed a dual pathology: a diffuse infiltrate of foamy macrophages typical of lepromatous leprosy, alongside a dense neutrophilic panniculitis characteristic of ENL. Crucially, Fite-Faraco staining demonstrated vast numbers of intact, solid-staining acid-fast bacilli, providing unequivocal evidence of active bacterial proliferation. Conclusion: This case demonstrates that a diagnostic algorithm integrating a high index of clinical suspicion with comprehensive bacteriological and histopathological methods is essential for accurately identifying relapse masked by ENL. The presence of viable bacilli confirms that ENL can be a direct clinical harbinger of relapse, mandating a dual therapeutic strategy that combines aggressive anti-inflammatory treatment with the immediate re-initiation of MDT.

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